pleural empyema (2)

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PLEURAL EMPYEMA
Department of Thoracic, General and Oncological Surgery
Medical University of Lodz
Head of the Department: Prof. Marian Brocki
Author of the lecture: Sławomir Jabłoński, MD
DEFINITION
Pleural empyema
or
thoracic empyema
The inflamatory process in a preformed
anatomical space defined by the visceral
and parietal pleura
Incidence & epidemiology
Empyema is the presence of gross pus in the pleural
cavity; it consists of an effusion containing
polymorphonuclear leukocytes and fibrin.
The Greek philosopher, Aristotle, recognized empyema
and described the drainage of pus with incision and a
metal tube as early as 300 BC.
A parapneumonic process is defined as a pleural
effusion associated with pneumonia, lung abscess or
bronchiectasis.
Not all parapneumonic processes are empyemas.
PLEURAL EMPYEMA (empyema pleurae)
Pleural empyema is a kind of exudative pleuritis caused
by microorganisms (bacteria, fungi, some protozoa) that infected
the pleural cavity.
Inflammation of organs or anatomical structures localized within
the chest and out its anatomical borders can caused a retention
of effusion in the pleural space (hydrothorax)
A reason for pleural effusions are also systemic diseases.
Initially sterile exudate can be resorbed by the pleura if a primary
disease is treated effectively.
The infection of the exudate causes its transformation into purulent
liquid that fills the pleural cavity and forms pleural empyema
(empyema pleurae).
PLEURAL EMPYEMA (empyema pleurae)
The presence of purulent liquid within the pleural cavity for several
Weeks leads to the formation of fibrin deposits on both the visceral
and parietal pleura and an imprisoning fibrothorax appears (fibrothorax).
Progressing empyema organization causes lung compression
and atelectasis, decreases lung volume and leads to inflammatory changes
within pulmonary parenchyma.
As a result ventilation and gas exchange disturbances are observed.
Within a fibrinopurulent capsule (membrana pyogenes) a collection
of pus is frequently present. However, septic liquid has no contact
with adjacent tissue well supplied with blood that’s why a clinical
presentation of empyema may be uncharacteristic and poorly expressed.
PLEURAL EMPYEMA (empyema pleurae)
PLEURAL EMPYEMA (empyema pleurae)
CLINICAL CONDITIONS CAUSING LIQUID RETENTION
IN THE PLEURAL CAVITY :
 TRANSUDATE - circulatory insufficiency, hepatic cirrhosis, nephrotic
syndrome, superior vena caval obstruction.
 EXUDATE – malignancy, infection, pulmonary embolism, esophageal
perforation, pancreatitis, sarcoidosis, systemic diseases.
 LYMPH (chylothorax) – trauma, surgery, malignancy, subclavian vein
thrombosis.
 BLOOD (haemothorax) - trauma, malignancy
In a case when a liquid collected in the pleural space becomes infected
by virulent microorganisms it transforms into pus.
Pleural empyema can develop in any individual but it seems to be more
frequent in younger people in whom immune system is weakened.
PLEURAL EMPYEMA (empyema pleurae)
The most frequent reason for pleural empyema are complications
of pneumonia (parapneumonic empyemas) and other diseases of tissues
adjacent to the pleural cavity.
An important etiological group for pleural empyema are complications
of surgical treatment of pulmonary, esophageal and mediastinal
pathologiesand frequent, repeated thoracocentesis for pleural effusion.
Lung resections with incomplete postoperative expansion of the lung
promote the formation of a cavity that creates good conditions for liquid
retention and its infection with bacteria from the bronchial tree, infected
postoperative wound or drains.
Complications of thoracic injuries and among them the infection of
non-evacuated posttraumatic hemothorax are significant etiological
factors of pleural empyema formation.
ETIOLOGY OF PLEURAL EMPYEMA
Etiology
%
Purulent pneumonia
50
Lung abscess rupture
1-3
Sepsis
1-3
Pulmonary tuberculosis
1
Mycotic lung infection
1
Trauma
3-5
Pulmonary, esophageal and mediastinal
surgery
25
Subphrenic abscess
8-11
Bronchial fistula causing spontaneous
pneumothorax
<1
Complications of parasitic invasion
<1
Others
1
PLEURAL EMPYEMA (empyema pleurae)
MICROBILOGY - BACTERIOLOGIC AGENTS:
Most common bacteriologic agents :
 pneumococus
 staphylococus
 streptococus
 haemophilus influenzae
 Gram-negative bacteria (pseudomonas, klebsiella,
enterobacteriace,escherichia coli)
 anaerobic bacteria
 mixed bacterial flora
PLEURAL EMPYEMA (empyema pleurae)
PATHOPHYSIOLOGY – ways of infection :
 DIRECT INFECTION through the chest wall as a result of
injury, thoracocentesis or surgical management (postoperative
pleural empyemas constitute approximately 25% of pleural
empyema cases)
 CONTACT INFECTION – infection spreads from underlying
infected pulmonary parenchyma, lung abscess, bronchiectases,
subphrenic or perinephric abscess.
 HEMATOGENOUS SPREAD
 LYMPHOGENOUS SPREAD
PLEURAL EMPYEMA (empyema pleurae)
PATHOPHYSIOLOGY
PHASES OF PLEURAL EMPYEMA FORMATION :
 Serous phase (exudative empyema): clear, straw-colored effusion
(pH>7.3, glucose concentration [GLU]>60 mg%, lactate
dehydrogenase activity [LDH] < 500 U/L )
 Fibrinopurulent phase (fibrinopurulent empyema): effusion contains
large numbers of bacteria and polymorphonuclear granulocytes,
intensification of clinical signs and symptoms of inflammation,
deposition of fibrin on both the visceral and parietal pleura
( pH < 7,1, GLU < 40mg%, LDH > 1000 U/L)
 Organizing empyema phase (organizing empyema) (fibrothorax) –
nonelastic, fibrinopurulent coat that imprisons the lung appears.
An empyema capsule contains pus.
PLEURAL EMPYEMA PHASES
Pleural empyema - Fibrinopurulent phase
PLEURAL BIOPSY
PLEURAL EMPYEMA (empyema pleurae)
CLASSIFICATION OF PLEURAL EMPYEMAS :
Etiological classification:
 specific (tuberculosis)
 non-specific – non-specific bacterial infection
 mixed
 mycotic
Pathogenetic classification:
 synpneumonic – empyema coexists with another lung
inflammation
 metapneumonic – it develops when a primary inflammation has
already regressed
PLEURAL EMPYEMA (empyema pleurae)
CLASSIFICATION OF PLEURAL EMPYEMAS :
Size criterion:
 non-localized empyemas – the whole pleural cavity is involved
 localized (encapsulated) empyemas - ( unilocular or multilocular)
Duration and pathologic criterion :
 acute empyema
 chronic empyema
Jatrogenic empyemas:
 empyemas with preserved
pulmonary parenchyma
 empyemas after lung resection
(pneumonectomy)
- with bronchial fistula
- without bronchial fistula
PLEURAL EMPYEMA (empyema pleurae)
CLINICAL PRESENTATION:
ACUTE PHASE:
CHRONIC PHASE:
 hectic fever
 shivering
 dyspnea
 toxemia
 chest pain
 tachypnoë
 asthenia
 lack of appetite
 weight loss
 chest wall inflammation
(sometimes)
 leucocytosis
 anemia
 expectoration of
purulent sputum
( if bronchial fistula
coexists)
 subfebrile body
temperature
 cachexia
 low body mass
 paroxysmal cough
 dyspnea
 contraction of
intercostal spaces
 scoliosis
 chest pain
 attenuation of
respiratory murmur
 dullness of sound
PLURAL EMPYEMA (empyema pleurae)
DIAGNOSIS :
 characteristic clinical presentation
 features of hydrothorax
in physical examination
 chest X-ray
 pleural ultrasonography
 computed tomography
 diagnostic thoracocentesis
( macroscopic features of liquid, positive bacterial cultures, glucose
concentration< 40 mg/dl, pH<7,0, LDH > 1000 U/L)
 flexible bronchoscopy (useful in a case of bronchial fistula)
 needle pleural biopsy
 diagnostic videothoracoscopy
 diagnostic thoracotomy
PLEURAL EMPYEMA (empyema pleurae)
ROENTGENOGRAPHIC APPEARANCE OF PLEURAL EMPYEMA :
 opacification of the costophrenic angle compatible with pleural effusion
(the beginning of the disease)
 roentgenographic features of lung compression caused by effusion
(Ellis-Damoiseau line)
 the presence of an empyema capsule, on a lateral projection empyema
has a D-like shape.
 the mediastinum is shifted to the contralateral side of the chest
 pneumothorax with airfluid level (if bronchial fistula is present)
 roentgenographic features of empyema and spherical opacification within
pulmonary parenchyma (empyema accompanied by lung abscess)
LUNG EMPYEMA (empyema pleurae)
TREATMENT :
The treatment of pleural empyema depends on its etiology, duration,
patient’s general state and concomitant diseases.
The general rules of empyema management are as follows: evacuation of
purulent liquid out of the pleural space, obliteration of the empyema sac and
augmentation of patient’s immune system.
Ubi pus evacua - ,,if you find pus remove it”
The goals of treatment in pateints with pleural empyema are :
1.
2.
3.
4.
5.
6.
7.
to save life
to elimintae the empyema
to reexpand the trapped lung
to restore the mobility of the chest wall and diaphragm
to return respiratory functionto normal
to eliminate complications and chronicity
to reduce the duration of hospital stay
(Mayo P, Saha SP, McElvein RB. Acute empyema in children treated
by open thoracotomy and decortication. Ann Thorac Surg. 1982;34:401-407)
TREATMENT :
ACUTE EXUDATIVE EMPYEMA :
 exudative empyema can be treated by aimed antibiotic therapy
and repeated needle aspirations of pleural effusion.
 simultaneously coexistent pathologies are treated and nutritional
therapy is carried out.
 intercostal tube drainage is usually a primary treatment for both
acute and chronic pleural empyema.
 intrapleural antibiotic administration
PLEURAL EMPYEMA (empyema pleurae)
TREATMENT :
CHRONIC EMPYEMA :
 suction intercostal tube drainage with interpleural antibiotic administration
 irrigating pleural drainage
 after 14 days a suction drainage can changed into an open drainage and
a patient can continue his or her therapy in an outpatient clinic.
 interpleural administration of fibrinolytic agents in a case of encapsulated
empyema (Streptokinase or Streptodornase for 3-5 days)
 videothoracoscopy with mechanical debridement of the pleural space ,
ablation of dividing walls within the empyema, partial decortication and
pleural drainage.
PLEURAL EMPYEMA (empyema pleurae)
SURGICAL MANAGEMENT :
 thoracotomy and decortication- if by intercostal tube drainage lung
re-expansion isn’t achieved (decortication- a nonelastic fibrinopurulent coat
is removed from the underlying lung and the chest wall to make re-expansion
of the lung possible)
 decortication and lung resection ( empyema is accompanied by lung abscesses,
lung mycosis or malignancy)
 chest wall fenestration- a technique used in debilitated patients. An upside down
U-shaped skin incision is made to form a musculocutaneous flap. Short
fragments of 2 or 3 ribs are resected over the most dependent part of the
empyema sac. Then the flap (Eloesser flap) is introduced into the pleural space
and sutured together with the parietal pleura. A kind of a channel is formed
that enables effective pus drainage and repeated introduction of gauze saturated
with antiseptic agents. Such a management leads to gradual sterilization of the
pleural space and its healing by granulation.
SURGICAL MANAGEMENT:
 in patients with pleural empyema after lung resection the ablation of the
empyema sac by a surgical reduction of its size is the main goal
(thoracoplasty, myoplasty, omentoplasty).
 in patients with pleural empyema with bronchial fistula after
pneumonectomy - removal of the empyema sac (membrana pyogenes) and the
closure of the fistula (myoplastic procedures- bronchial fistula is covered with
a pedunculated muscle bundle) plus thoracoplasty.
 Clagett procedure - chest wall is fenestrated. When the healing of the parietal
pleura by granulation appears the fenestration is closed and the pleural space is
sterilized by its filling throughout a drain with a solution of antibiotics selected on
the basis of bacterial cultures
 Weder procedure- three successive thoracotomies are performed every 2-3 days.
During the first and the second thoracotomy fibrinopurulent empyema sac is
removed and gauze saturated with antibiotic solution is placed within the pleural
space. During the third thoracotomy gauze is removed.
SURGICAL MANAGEMENT OF PLEURAL EMPYEMA:
VATS decortication and irrigation pleural space
Treatment of pleura empyeme
Thoracocentesis
Clear liquid
pH>7.20
pH<7.20
No intervention Reccurent thoracocentesis
Not clear or purulent effusion
Not loculated
Loculated
Drainage
Pleural lavage
Drainage
Pleural lavage
Fibrinolytics
Failure
VATS
Surgery
Hamm et al, ERJ 1997
ELLOESAR FLAP IN PLEURAL EMPYEMA TREATMENT
THORACOPLASTY
THORACOPLASTY
DECORTICATION
DECORTICATION
MYOPLASTY in treatment of bronchial fistula post pneumonectomy
Muscle Flap Interposition
Post lung resection empyema
Post lobctomy(0,01%-2,0%), post pneumonectomy (2%-16%),
residual space and air leak
Methods of tretment: - Muscle flap clousure
- Limited thoracoplasty
- Open window thoracostomy
The Clagett procedure -open-window thoracostomy
in patient with pleural empyema and bronchial
postpneumonectomy fistula (own meterial)
PLEURAL EMPYEMA (empyema pleurae)
EMPYEMA COMPLICATIONS :
 atelectasis and respiratory insufficiency
 bronchopleural fistula
 pleurocutaneous fistula
 pleuroesophageal fistula
 sepsis
 peritonitis
 metastatic abscesses
 purulent inflammation of the chest wall
 progressive respiratory insufficiency
PLEURAL EMPYEMA (empyema pleurae)
PROGNOSIS :
Mortality in patients with pleural empyema ranges from 1% to 19%.
A reason for death in an acute phase of empyema is sepsis or other
complications of generalized infection.
Late deaths are caused by toxemia, respiratory insufficiency or
multiorgan failure.
In patients with concomitant diseases such as diabetes mellitus,
malnutrition, systemic diseases, malignancy and alcoholism mortality
reaches 40%.
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